A brachial plexus injury, although not very common, can occur from sports contact, motor vehicle accidents and even child birth. In severe cases, symptoms can include paralysis of the upper extremities and take months to recover and rehabilitate.
In this article, we will help to provide a summary of the variety of causes and the associated symptoms for a brachial plexus injury. We will also discuss how a physiotherapy treatment approach can help resolve and manage symptoms associated with these injuries.
What is the Brachial Plexus?
The five nerve roots (anterior rami) exiting from C5 – T1 of the cervical and thoracic vertebral spine form the network of nerves comprising the brachial plexus. These nerves start at the neck, pass under the clavicle and travel under your axilla (armpit) and throughout your shoulder, arm and hand. Signals sent via the brachial plexus are responsible for your sensory, autonomic and muscle control of the upper extremities and more.
The brachial plexus is subdivided into five sections (roots, trunks, divisions, cords and branches) that end by becoming peripheral nerves for the shoulder, arm and hands. These roots have multiple connections as they travel away from the spinal cord and to the periphery of the upper limbs. These connections allow for redundancy in the signals being sent to the upper limbs. This redundancy allows multiple signals to be sent from the spinal cord to the same location in case one area becomes damaged or injured.
Brachial Plexus Injury Signs and Symptoms
An injury to the brachial plexus can cause a variety of symptoms to varying degrees. The clinical picture of the injury is based on the location and extent of the injury.
In mild cases, symptoms might be described as a tingling or stinging sensation. In more severe cases, symptoms can include partial or full paralysis of muscles in the hand, the forearm, the upper arm and parts of the shoulder. These patients may describe a weakness or heaviness of the arm that will correspond with the affected area.
Also, individuals suffering a brachial plexus injury may have loss of or altered sensation to the upper limb. Lastly, in some cases, the individuals may suffer from Horner’s Syndrome if the sympathetic nerves are affected. This will cause constriction of the eyes (miosis), the upper eyelid to droop (ptosis) and an inability to sweat (anhidrosis).
What Causes Brachial Plexus Injury?
A brachial plexus injury most commonly occurs from sports contact, motor vehicle accidents and from delivery at birth.2 The actual mechanism for these injuries is either from a stretch, a compression or from impact.
If the arm or neck is moved in a significant manner to cause traction of the upper extremity from the body such as in a motor vehicle accident, it can create a pull on the nerves. If the pull is substantial, it will create tension on the nerves which in turn can create lesions on the nerves or could possibly result in the nerves being torn away (avulsion).3 Depending on the movement and extent of stretch, this will determine the location and extent of injury.
Impact injuries are from direct contact to the brachial plexus. Impact can cause lesions or tears if significant enough.
Compression injuries can happen from increased pressure caused by a tumor or fluid in the area. Also, it can occur from a fracture of the clavicle that causes compression from the healing process (inflammation and callus formation).3
Information on the prevalence of severe brachial plexus injuries in adults is sparse. However, recent literature states the prevalence is 1.64 people per 100,000.4 Further, the prevalence following a traumatic injury such as a motor vehicle accident was stated as 1.2% of individuals.5 While the prevalence in live births is 0.5-3 for every 1000 births in the United States. Additionally, 30% of those injuries resulted in permanent injury to the child.6
Classifying Brachial Plexus Injury
Injuries to this area are often categorized in multiple ways. The simplest description is a traumatic or non-traumatic injury. Injuries can also be classified based on the location in relation to the clavicle. There are supraclavicular (which are the most common), retroclavicular and infraclavicular injuries. The location will determine which area of the brachial plexus may have been affected.1
The other categorization is by using the Leffert classification which is as follows:
- I – Open
- II – Closed
- III – Radiation Induced
- IV – Obstetric
- IVa – Erb’s (upper root)
- IVb – Klumpke (lower root)
Brachial Plexus Injury Treatment
The treatment approach for brachial plexus injury relies heavily on the symptoms and severity of the injury present. Significant injuries that have caused ruptures or avulsions will often be treated surgically, if possible. Surgical intervention will include a nerve graft of the damaged to nerve to regain function.7
Physical therapy has a role in helping people with milder brachial plexus injuries, as well as the rehabilitation phase that is vital in helping clients recover from a surgically repaired nerve in the brachial plexus. Individuals in the latter case will require intensive physiotherapy treatment to be able to return to normal function.
Nerves recover and heal much differently than sprains, strains and fractures. Nerves recover much slower and the process to heal from a brachial plexus injury is more likely to take years and not months.
- Treatment for a brachial plexus injury will include:
- Maintaining mobility of the affected areas through passive and active range of motion8
- Regaining and promoting strength through active exercise. Also, promoting strength to maintain function for activities of daily living. Strength will also help support structures of the upper limb to avoid injuries in the future.7
- Utilize modalities such as acupuncture to calm the nervous system and reduce pain
- Education on how to manage symptoms during recovery such as pain, limited motion, swelling, tightness and fatigue
- If needed, therapists can recommend and create adaptive devices to make daily activities easier
At Propel Physiotherapy, our highly experienced clinicians are skilled in the management of a variety of complex conditions. Physiotherapy treatment plays a large role in improving the detrimental effects that can arise from a brachial plexus injury. If you are suffering from a brachial injury or suspect you may be suffering from this, come see one of our therapists so they can help improve your function.